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ABSTRACT

Study Objectives:

Severe events of respiratory distress can be life threatening. Although rare in
some outpatient settings, effective recognition and management are essential to
improving outcomes. The value of high-fidelity simulation has not been assessed
for sleep technologists (STs). We hypothesized that knowledge of and comfort level
in managing emergent pediatric respiratory events would improve with this innovative
method.

Methods:

We designed a course that utilized high-fidelity human patient simulators (HPS)
and that focused on rapid pediatric assessment of young children in the first 5
minutes of an emergency. We assessed knowledge of and comfort with critical emergencies
that STs may encounter in a pediatric sleep center utilizing a pre/post-test study
design.

Results:

Ten STs enrolled in the study, and scores from the pre- and posttest were compared
utilizing a paired samples t-test. Mean participant age was 42 ± 11
years, with average of 9.3 ± 3.3 years of ST experience but minimal experience
in managing an actual emergency. Average pretest score was 54% ± 17% correct
and improved to 69% ± 16% after the educational intervention (p < 0.05).
Participant ratings indicated the course was a well-received, innovative educational
methodology.

Conclusions:

A simulation course focusing on respiratory emergencies requiring basic life support
skills during the first 5 min of distress can significantly improve the knowledge
of STs. Simulation may provide a highly useful methodology for training STs in the
management of rare life-threatening events.

Severe events of respiratory insufficiency are seemingly rare events in some clinical
outpatient centers, such as sleep centers.1
Nevertheless, they can and do occur. These life-threatening events must be identified
quickly and effectively managed to ensure the best chance for survival. The American
Association of Technologists in Sleep (AATS) mandates performance of certain duties
of sleep technologists (STs). These include: (1) the ability to recognize and respond
to critical events occurring during the polysomnographic monitoring of variables
such as cardiac arrhythmias, oxygen desaturation, breathing distress, and other
medical emergencies; and (2) the ability to perform or assist with basic cardiopulmonary
resuscitation (CPR) if required and ensure the simultaneous alerting of on-call
responders or emergency services personnel.2
In addition, the American Academy of Sleep Medicine (AASM) requires that STs complete
such a course on a yearly basis to meet accreditation standards.3 However, there are no data to suggest the most efficacious
method of teaching CPR skills to STs.

Currently, many STs prepare for these emergencies by taking a designated health
care course, such as the Basic Life Support (BLS) for Healthcare Providers for training
in CPR.4 Although beneficial, such didactic
curriculums are dedicated to teaching acute recognition and management of a broad
set of patient problems. The majority of the curriculum is unlikely to be applicable
to STs and the emergencies they may encounter. In addition, there is literature
documenting the rapid decay of skills and knowledge of BLS, Advanced Cardiac Life
Support (ACLS), and Pediatric Advanced Life Support (PALS) for physicians, residents,
and nurses. This decay may be even more substantial in settings in which opportunities
to practice the skills are often infrequent.5–10 Since STs tend to be faced with identification
of and the need to respond to emergent situations much less often than residents,
it would be expected that STs have an equal or greater decline in these skills.

BRIEF SUMMARY

Current Knowledge/Study Rationale: To date, methods of training in emergent
procedures for sleep technologists have not been evaluated. We assessed the impact
of a high-fidelity simulation training for sleep technologists that may be faced
with severe events of respiratory insufficiency.

Study Impact: Life threatening emergencies are rare in sleep centers, yet
do occur. Simulation for sleep technologists may be a beneficial method of training
to bridge the gap between opportunity to practice emergency management skills and
reality.

Alternative forms of emergency training, such as high-fidelity simulation scenarios
depicting high acuity events, may improve the immediate and long-term performance
during actual rare emergency events. Simulation can involve a combination of actors
who portray patients and healthcare professionals and/or high-fidelity full-body
human patient simulators. Thus, simulated activities offer an additional method
of building and retaining application skills. For example, Edgar reported that lectures
and other passive forms of teaching have only a 10% to 20% retention rate after
6 weeks, whereas active forms of learning, such as simulation, improve retention
rates to as high as 70%.11,12 High-fidelity simulation is gaining acceptance
as an effective tool to train medical personnel and students in many disciplines
and has acquired applications in laparoscopic surgery, ophthalmology, emergency
medicine, pediatrics, and other high acuity settings.13–19
Simulation cases can be created to be context specific, to allow for application
in various less traditional areas such as radiology and pharmacy.20,21

To date, efficient, innovative, and successful methods of training in emergent procedures
for STs have not been evaluated. Emergency policies and procedures are documented
and reviewed routinely as part of AASM accreditation requirements for sleep centers;
however, methods for ensuring sleep technologists are confident and able to respond
in rare emergencies have not been reported. The utilization of HPS in a sleep center,
particularly one that focuses on pediatrics has not been reported. Our hypotheses
were that (1) simulation would be well-received by STs as an innovative educational
opportunity, and (2) simulation would be an effective methodology for STs to improve
the identification of and immediate critical actions for severe respiratory insufficiency
that can occur in medically complex children undergoing nocturnal polysomnography.

METHODS

This study was approved by the Institutional Review Board of Human Studies at University
of Alabama at Birmingham.

Course Conceptualization

The Pediatric Sleep Disorders Center at the Children's Hospital of Alabama is an
8-bed center with 2 inpatient portable monitoring units. The center studies approximately
1600 pediatric patients per year. Of these 1600, approximately 20% are patients
with multiple medical complexities. For example, the center routinely studies patients
with severe pulmonary complications to evaluate the need or settings for supplemental
oxygen, ventilation, and noninvasive ventilation, as well as tolerance of capping
of the tracheostomy tube and readiness for decannulation in medically complex children.
After debriefing a recent emergency in our pediatric sleep center, our STs expressed
concerns with their confidence and ability to identify and manage critical situations,
particularly respiratory distress in infants and children. Specifically, STs identified
infants as the most difficult age to assess and treat. Given the high acuity of
our patient population coupled with our staff concerns, we designed and evaluated
an innovative simulation sleep medicine curriculum for the sleep center staff in
collaboration with the Pediatric Simulation Center at the Children's Hospital of
Alabama. This center has extensive simulation experience, having conducted pediatric
simulation training with more than 12,000 participants, ranging from students to
advanced learners.

Course Design

The course emphasized observable signs of respiratory distress as well as treatment
decisions and the actions required to carry out these decisions during emergent
events. Since most STs would call an emergency response or code team for assistance
with a crisis situation, we focused on those treatments important during the first
5 minutes of an emergency, prior to the arrival of help. In groups of 3 to 4 STs,
participants took part in a simulation course with additional time for completion
of the pretest, posttest, and post course-survey (Appendices A
& B). Course objectives included that the learner would
be able to (1) assess a patient prior to a sleep study and know the proper procedures
to call for help, (2) determine a Pediatric Early Warning System (PEWS) score22 for each participant and follow an escalation
algorithm, and (3) initiate proper BLS skills, including bag-valve-mask ventilation
and chest compressions.

All simulation sessions were conducted at the Pediatric Simulation Center utilizing
high-fidelity simulator mannequins including SimBaby (Laerdal, Wappingers Falls,
NY) and Pediatric Hal 1-year-old (Gaumard Scientific, Miami, FL). The SimBaby can
cough, cry, or grunt to indicate distress, while the Pediatric Hal uses early toddler
words to answer simple questions. During the simulations a “parent”
was with each child and could also describe or express concern over the patient's
level of respiratory distress. The simulators also have pulses, chest rise, heart
sounds and lung sounds, an intravenous line, and an intramuscular injection site.
These mannequins provide a platform to carry out a number of procedures from basic
intravenous fluid administration, bag-valve-mask ventilation, and chest compressions,
to more advanced techniques such as endotracheal intubation. Monitors can reflect
various vital sign changes, including heart rate, blood pressure, oxygen saturation,
and respiratory rate based on the decisions made and treatment administered during
the simulations. Scenarios began with the STs recognizing a patient problem and
calling for help. Each scenario included an actor who played a family member to
add to the realism of the experience. Each room had oxygen delivery devices which
could be connected to an oxygen flow meter, simulated medications which could be
drawn up and given in the appropriate dosage, and a code cart for any needed supplies.
The level of assistance that needed to be called depended on the severity of each
scenario. Options for help included notifying the sleep attending physician, the
rapid response team, or the code team. When help arrived, efficient and concise
handoffs were necessary to transfer care adequately.

The course consisted of a 10-min introduction to the simulation center and the simulators'
features. This was followed by a 10-min standard lecture presentation of a rapid
pediatric assessment, specifically focusing on signs and symptoms of respiratory
distress and poor circulation in children with appropriate interventions. STs then
participated in 3 simulation scenarios involving different levels of respiratory
distress. Each scripted scenario lasted approximately 10-15 minutes and was followed
by a 15-min debriefing by simulation personnel. All simulation activities were led
by the same instructor in order to decrease the variability of the experiences.

The first scenario involved a 6-month-old with mild respiratory distress scheduled
for a sleep study to evaluate oxygen requirement. The participants interacted with
the child's mother and assessed the patient. Participants determined if they should
notify the sleep study physician. Afterwards, debriefing allowed for participants
to self-reflect, and a discussion of infant assessment followed. Emphasis was placed
on calling the sleep attending physician whenever the STs were concerned regarding
a patient. The PEWS score was introduced.22

The second scenario involved a 1-year-old with a tracheostomy admitted for a sleep
study to evaluate for possible decannulation. This patient had vital signs at the
upper limits of normal for his age. By talking with the child's mother, assessing
the patient and using the PEWS scoring,22
the participants needed to determine if interventions or calling the physician were
warranted. Debriefing followed and included reviewing PEWS scoring22 and introducing the algorithm for activating the rapid response
team in the hospital.

The third scenario involved a 9-month-old infant with a tracheostomy who was admitted
for a sleep study to be conducted while the tracheostomy was capped to evaluate
possible decannulation. Once the obturator was placed, he had increased respiratory
distress, manifested by grunting, retractions, increased respiratory rate, decreased
oxygen saturation, and coughing. Upon further questioning of the patient's mother,
it was discovered that the child had an upper respiratory infection as well. The
participants needed to assess the patient and recognize that the patient needed
the obturator on his tracheostomy tube removed, and the physician needed to be notified.
If this process was delayed, the patient further deteriorated, manifesting as apnea
the need for the code team to be called. Debriefing allowed ample time for participants'
self-reflection. A discussion regarding the procedure for calling a code then ensued.
Effective communication during hand-off with the code team was reinforced.

All sessions were videotaped and were followed by an immediate debriefing session
utilizing the model of debriefing with good judgement.23
This model is taught at the Center for Medical Simulation, Boston, MA, and is anchored
in organizational behavioral science. This model aims to identify and clarify the
reasoning behind decisions that result in actions or inaction during a simulated
case.

Data Analysis

Data were analyzed using SPSS Version 11.5 (SPSS, Inc, Chicago, IL). Data are presented
as means and standard deviations. Mean differences for pre- and posttests and comfort
scales were examined using paired samples t-tests (2-tailed); and a p value
< 0.05 was considered significant.

RESULTS

Fifteen STs participated in the simulation course in 3 groups of 4 and one group
of 3 as part of routine yearly training. All participants participated in the educational
component with 10/15 (66%) agreeing to enroll in the research component. Demographics
and prior exposure to codes are reported in Table 1. Only
one participant had significant experience with emergencies due to prior job experience
as a respiratory therapist with a primary duty of responding to critical events.
Overall, the simulation course resulted in significant improvement in knowledge.
The average pretest score was 54% ± 17% and improved to 69% ± 16%
after the educational intervention (p = 0.05). When examining specific items, the
greatest improvement was seen in basic CPR skills. For example, an improvement of
60% was seen on question 10 (“When performing CPR, make sure your compression
rate is approximately…”), which improved from 40% to 100%. In addition,
great improvement was seen on question 5 (“A baby is breathing 120 times per
minute with supracostal retractions, you could assess all of the following except…”),
which improved from 50% to 80%. In addition, a 30% improvement from 10% to 40% on
question 3 was seen (“What is the normal breathing rate for an infant under
the age of 1 year?”). The pre and posttest items can be seen in Appendix A (appendices are available online at www.aasmnet.org/jcsm).

Table 1

Finally, the mean score on the Simulation Course Comfort Scale (Appendix
B) prior to the course was 20.2. After the course, the score increased
to 21.1 (p = 0.24). Course evaluations were overwhelmingly positive. There was 100%
agreement that both the simulation scenarios and debriefing exercises were a valuable
learning experience. Themes of learning included the “realism of the experience”
and the “opportunity to practice emergent scenarios occasionally encountered
in the sleep center.” One ST commented, “I think this is the best experience
for patient care workers. We really get a chance to fine tune and improve our skills
here.”

DISCUSSION

Based on our outcome measures, the simulation course for STs, focusing on the first
five minutes of emergent events, was effective at increasing knowledge. While there
was not a significant improvement in comfort level, the STs improved in their knowledge
and management of the first five minutes of an emergent event. The initial moments
of a crisis are the most critical and were described by STs as the most challenging
and difficult time frame. This course was designed specifically for this time period
and appears to have been successful.

Our data show that most STs do not have enough actual experience to be proficient
at these events. Simulation allows reproduction of rare events, such as medical
emergencies in the sleep center, providing an opportunity for active learning. In
our initial emergency debriefing with the STs, confidence and ability to respond
to critical situations was shown to be extremely low, which negatively impacted
job satisfaction. Confidence and ability during emergent events were perceived by
STs as barriers to their implementation of emergency management skills. Opportunities
for the application of this material are rare in a sleep center, yet actual emergencies
do occur. Without practice and feedback, staff are at risk for failing to identify
distress and failing to respond appropriately to a life-threatening emergency. Simulation
offered a valuable tool for addressing an expressed need for further training and
experience in identification of distress and effective response management. In addition,
simulation provided an opportunity to practice and apply this knowledge in a “real
world” setting. Like other studies, high-fidelity simulation learning activities
in the context of STs were well received and complemented other forms of instruction
currently offered, such as BLS.

In addition, it should be noted that respiratory emergencies are only one type of
emergency that STs could encounter in the sleep laboratory. For example, seizures
and cardiac arrhythmias require emergency responses by the staff. Thus, simulation
also offers a possible educational method for improving the knowledge and management
skills of STs regarding other emergencies (such as recognizing seizures), such as
when to contact emergency response teams and immediate management until a response
team arrives.

The simulation center relies heavily on the six core adult learning principles introduced
by Malcolm Knowles: (1) adults need to know why they need to learn something before
learning it; (2) adults want to be self-directing in their learning; (3) adults
have rich past experiences which shape their current learning; (4) learning needs
to be temporally related to real-world application; (5) orientation to learning
needs to be task-centered not subject-centered; and (6) internal motivators are
important for adult learners.24 The center
also focuses on reflective learning by utilizing debriefing with good judgement.23,25
This cycle begins with an experience (either actual patient encounter or simulation),
followed by reflective observation, abstract conceptualization, and finally, active
experimentation. Debriefing augmented their learning by allowing instructors the
opportunity to point out correct and incorrect actions and to further explain concepts
experienced in the simulation. The post-simulation assessment in this study showed
that all STs recognized the importance of this process to further their understanding
of the scenarios.

Simulation was shown not only to be a useful and well received method for training
in the identification of an emergent situation, but also beneficial
for training in the response process during the acute event. The course
was designed to provide additional training in the call for help and hand-off processes
that technologists rarely encounter. The technologists overwhelmingly indicated
that the realism of simulating communication procedure in these two situations was
extremely valuable. Prior to this training, STs felt they were minimally familiar
with the hospital emergency response team and the desired information that needed
to be disseminated upon their arrival. Providing structure and training in this
process has been shown to significantly reduce medical error, patient harm, and
staff communication errors often encountered in such high-risk situations.26,27

Similar to other studies, our project further demonstrates that simulation is an
effective, well received, and a useful method for a group of pediatric healthcare
providers who otherwise may not be included in mainstream simulation activities.
As a result of this project, the sleep technologists requested that this training
be conducted on a regular basis, and the program is now required yearly for all
STs and sleep center staff. Furthermore, the AAST advocates that training and continuing
education in emergency procedures is required for sleep technologists,2 and the AASM requires CPR training as a necessary
component for accreditation of sleep centers.3
Simulation centers may allow for expanded application activities augmenting and
improving a didactic curriculum.

As this project evolved from a quality improvement needs assessment, there are limitations
of our design. First, we did not assess individual learning or performance. Second,
we evaluated knowledge of emergency skills but did not assess actual management,
for example, during a “mock code” assessment. Third, we did not evaluate
the optimal time period in between teaching and retraining. With the positive learner
feedback, future studies are being designed to help determine the optimal time needed
for each learner of each session and frequency of retraining that might be needed
to prevent decay of skills and knowledge. In addition, checklists of required actions
are being developed to behaviorally evaluate the STs during a “mock code.”
Thus, further research is needed before we can confidently advocate that the inclusion
of a simulation course should be mandated in the training of all STs and sleep center
staff. For example, direct comparisons of simulation and other traditional learning
methods should be conducted.

In conclusion, although simulation requires significant resources, it offers an
exemplary and valuable technique to improve sleep technologists' critical thinking
and application skills. This report describes the first known use of high fidelity
simulation for STs. Significant improvement in knowledge of respiratory distress
in children occurred. Further study is needed to better characterize learning patterns
and to identify the optimal frequency of need for training.

DISCLOSURE STATEMENT

This was not an industry supported study. The authors have indicated no financial
conflicts of interest.

Chamberlain D, Smith A, Wollard M, authors. Trials of teaching method in basic
life support: comparison of simulated CPR performance after training and at 6 months
with a note on the value of retraining. Resuscitation. 2002;53:179–87. [PubMed]

9-month-old breathing 34 times per minute with mild retractions, parent feels that
is their baseline

A 10-year-old with asthma is undergoing a sleep study. They are apneic and have
no pulse. What is the correct ratio of chest compressions to ventilation?

30:2

15:2

5:1

10:1

What is the normal breathing rate for an infant under the age of 1 year?

12-16

60-90

20-30

30-60

All of the following are signs of respiratory distress except:

Tachypnea

Nasal flaring

Loud coughing

Wheezing or grunting

A baby is breathing 120 times per minute with supracostal retractions. You would
assess all of the following except:

Airway is clear

Color

Responsiveness

Respiratory rate

Parent report of medicines taken in the past 24 hours

At Children's Hospital, we have a CHAT team, otherwise known as the rapid response
team. In which of these scenarios would you need to call CHAT?

10-year-old with mild wheezing, no respiratory distress

2-year-old with temperature 103, sore throat, increased heart rate

5-year-old with tracheostomy who has increased secretions of dark color

6-month-old with increased work of breathing, oxygen saturation 90%

A 2-year-old boy with tracheostomy presents for sleep study. The sleep technologist
places the cap on the tracheostomy tube prior initiating the study. Within 10 minutes,
you notice the child's face is cyanotic, the oxygen saturation is 65%, and mental
status is altered. What do you do first?

Remove cap

Call CHAT

Give nebulizer

Call attending MD on call for the sleep center

Which of the following best describes the PEWS?

A scale to determine if the patient needs to be admitted to the hospital

A prioritized assessment of patient status to avoid events leading to respiratory
distress

A coma scale used in the Intensive Care Unit

A fellow sleep technologist is nervous and is bagging a 14-year-old child at the
rate of 50-60 times per minute. You recommend they bag at what rate?